“If you come to a fork in the road, take it.”

The pathway to a career in cardiovascular medicine is no short journey. As cardiology continues to grow within several of its subspecialized imaging and procedural areas, fellows-in-training (FITs) are uniquely poised to build a multifaceted career in academic or private practice. However, FITs transitioning to early career are faced with several challenges. The realities of a changing health care landscape, physician compensation measured in relative value units (RVUs), obtaining grant-funded research, and participating in mentorship or trainee education are just some of the challenges that FITs must navigate as they transition to early career. As I deliberate on the priorities that will shape my own future career in cardiology, I feel the imperative to offer several considerations as fodder for my colleagues in training who will soon find themselves at this crucial decision point.

It is important to first identify some of the central reasons why cardiology FITs choose academic or private practice. In a white paper by Tong et al titled, “Challenges facing early career academic cardiologists,” the investigators state that a recent survey by the American College of Cardiology estimated that 7% to 10% of cardiologists in early career are identified as academic. Thus, the vast majority of FITs will transition to nonacademic careers. However, the changing environment in which we practice continues to reshape the academic and nonacademic experiences, thereby further blurring the lines between the two arenas. For instance, as academic training programs expand their reach and affiliate with community hospitals, cardiologists in private practice increasingly find themselves educating residents and fellows. Additionally, partnerships with industry have enabled many in private practice to participate in clinical research and build personalized niche areas of clinical expertise. Table 1 lists many of the traditional reasons for why some choose academic or private practice careers in cardiology:

Academic and private practice experiences in cardiology will continue to have greater overlap as we face changes in health care delivery, reimbursements, and new metrics of quality and physician productivity. Furthermore, many of the traditional reasons outlined in Table 1 are becoming less applicable in current practice. As an example, physician autonomy has greatly decreased in the private practice environment, given that many private cardiology groups have merged into larger consortiums or have been bought by health care systems. Correspondingly, changes in the finances of academic medical centers have significantly affected many of the nonsalaried benefits of the academic experience. Therefore, as FITs deliberate on the career path that best suits their goals, here are 10 guiding principles to help navigate the choice between academic and nonacademic careers:

• 1.
  

  Know your pyramid of priorities: It is highly improbable to build a career that gives equal weight to every priority. Drawing out a classic pyramid with 4 sections and filling in what individually matters most or least is a good place to start. This simple exercise helps to codify that some priorities must be chosen over others.

  
  
• 2.
  

  Choose the career path that helps you advance your competitive frontier: Multinational corporations and large conglomerates use this economic concept to stay ahead of the fray in the marketplace. As one transitions to early career, they can apply this concept on an individual level with the goal of both contributing to their field and maintaining a growing fund of knowledge. Advancing your competitive frontier in cardiology might include:

  
  
  
  
  • a.
    

    Exclusivity in performing a particular advanced procedure that is not widely available.

    
    
  • b.
    

    Using and interpreting an advanced imaging technique in diagnosing and treating cardiovascular disease both in and out of the procedure laboratory.

    
    
  • c.
    

    Being a trialist or having access to novel therapeutics for your patients.

    
    
  • d.
    

    Balanced and regulated partnerships with industry to educate colleagues and use new equipment or techniques.

    
    
  • e.
    

    Participation in academic societies and committees to review research proposals, review quality metrics, contribute to guidelines, or formulate educational tools.

    
    
  • f.
    

    Involvement in fellowship training programs to shape the next generation of cardiologists.

  
  
  
  
• 3.
  

  Academic careers are heterogeneous: There are several pathways within an academic career track. When considering the range of academic cardiologists, from physician-scientists to pure clinicians, it becomes clear that those committed to academia have several choices. However, for those interested in the physician-scientist or scientist-researcher pathways, success will generally go to the individuals who have laid the foundation early in their training to learn the skills of grant writing from mentors and devote themselves fully to the pursuit of scientific inquiry. In contrast, the pure clinician or clinician-educator pathways allow entry for those FITs who want the feel of academia without the requirements to do intensive research. Essentially, the current model of academic jobs in cardiology is not the homogenous experience that it once was. This has presented FITs with many opportunities to remain in academics after training.

  
  
• 4.
  

  Understand the impact of nonreimbursable activities: Increasingly, both academic and nonacademic cardiology environments are linking physician compensation to RVUs generated through patient care. This means that as academic cardiologists are devoting time toward administrative roles or educating residents and fellows, there are no defined RVUs to reflect the time spent in these very important pursuits. Similarly, as physician-scientists make important contributions to research, the academic environments in which they thrive often do not have systems in place to assign RVUs or compensation for their efforts. These realities highlight that many of the pleasures and responsibilities within the academic career path are often nonreimbursable. This reality can often lead to incongruence between work and compensation. Interestingly, although private practice jobs are generally regarded as being balanced between work and compensation, future changes in their structure may yield many of the same incongruences with regard to nonreimbursable activities. In short, many of the important and honorable pursuits within academia do not necessarily offer monetary reimbursements to the physicians that brave these necessary challenges.

  
  
• 5.
  

  Private Practice is changing: The term “private practice” is gradually becoming obsolete. Solo practitioners and medium-sized groups are merging into larger groups or being bought by growing health systems. Although the traditional concept of private practice may continue to thrive in certain regions of the United States, the vast majority of cardiologists formerly in private practice will eventually become health system employed or part of a larger group. Understanding how these changes will affect income potential, professional growth, and accessibility to cutting-edge cardiovascular therapeutics is essential for those committed to the current concept of a private practice career.

  
  
• 6.
  

  Invest in your success: Choose the career opportunities where colleagues and mentors are invested in your success. One can choose an attractive academic or private practice job, but it will not translate into success or fulfillment if your partners/colleagues are undercutting your efforts to grow your patient base, develop your research, or expand your skills in a new direction. Similarly, opportunities with limited resources for cardiovascular diagnostics or therapeutics will directly limit the scope of your practice. Limits in scope of practice can sometimes negatively affect the depth and breadth of your knowledge and your ability to deliver the most complete care to your patients. Choose the opportunities that will give you access to the physician colleagues and physical resources that will advance your career.

  
  
• 7.
  

  Medical Education and its impact on your practice experience: Medical education remains one of the great bastions of academia. It is the central portal by which we train future cardiologists; one can easily grasp the exponential impact of teaching 1 student who then goes on to teach many. The academic career path engenders mentor-mentee relationships and promotes life-long learning. Participation in resident and fellow education serves to compound the synergy of mentorship, professional networking, and can lead to lasting personal friendships. In talking with academic mentors, these aspects of medical education are often cited as one of the most rewarding (and nonsalary) benefits of being an educator. However, an increasing number of private practice cardiology jobs also allows for exposure to resident and fellow education. This has truly changed the private practice experience for many cardiologists. Moreover, physician partnerships with industry provide opportunities to get involved with fellowship education on a national level (e.g., fellows courses or sponsored conferences). As we anticipate upcoming changes to the cardiology core competencies in fellowship training, the future direction of medical education may bring continued challenges with regard to balancing trainee education and patient care.

  
  
• 8.
  

  Income and Work Intensity: The changing health care environment has markedly affected the income-earning potential within various areas of cardiology. Traditionally, although private practice jobs previously paid significantly more than academic institutions, the income gap is now gradually narrowing. Although the income for academic and private practice jobs may approach some median level, there may continue to be higher paying private jobs in underserved areas for the foreseeable future. However, it is important to dispel any false notions that academic jobs are less intense than nonacademic jobs; this is simply not the case when considering the many changes that have affected both environments. Certainly, there are inevitable differences in the way that clinical work responsibilities are arranged (i.e., calls, workflow) or the impact of administrative roles, trainee education, and research responsibilities. But, in the current environment of patient care delivery, both academic and nonacademic cardiologists are spending significant work hours per day to meet several challenges including caring for complex patients, educating tomorrow’s physician leaders, and working after-hours to complete investigative research or take overnight calls. In short, few lucrative jobs in cardiology allow you to simply sign off, and for many, the work continues in some form long after the day has ended.

  
  
• 9.
  

  Understand how your practice goals affect your opportunities: Growth within imaging and procedural aspects of cardiology has led to a promising area of catheter-based and/or robotic structural, peripheral, and electrophysiological interventions. These advanced procedures continue to push the envelope at redefining the scope of what is possible through nonsurgical techniques. As leaders in our field continue to refine technique and device delivery systems, advanced fellowship training programs are starting up across the country to train the new wave of “structuralists.” The practice of structural heart interventions (i.e., transcatheter aortic valve replacement, MitraClip® Abbott Vascular, Melody® Medtronic transcatheter pulmonary valve) currently appears to be most facilitated at large academic institutions with experience and high volumes. Thus, FITs who make a commitment to do further training in structural heart interventions are essentially committing themselves to academic medical center–based employment in some form. Similarly, if your goal is to become involved in implantation of mechanical circulatory support devices such as, TandemHeart (CardiacAssist, Inc., Pittsburgh, Pennsylvania) or extracorporeal membrane oxygenation (ECMO), then higher volume academic centers tend to be the favored destination for critically ill patients in need of advanced circulatory support. Alternatively, many forms of peripheral intervention and advanced cardiac ablation procedures can generally be practiced in both academic and nonacademic settings.

  
  
• 10.
  

  Follow your passion and gut instincts: The concepts outlined earlier in themes 1 to 9 are not meant to be a complex titration in a multivariate equation. Rather, they are offered as a guide when deliberating on the best career path that suits one’s goals. However, sometimes the raw nature of trusting your instincts about a particular job opportunity can be your most powerful guide. FITs transitioning to early career should chase what they love about cardiology and pursue it to the fullest. This type of devotion can act like a magnetic force that pulls all the other factors into alignment to help you mold the career of your dreams.

The choice between academic or private practice careers in cardiology is about selecting the opportunity that best suits your goals; there is no right or wrong choice. The academic and nonacademic environments within cardiology are continually changing, and over time, there are fewer overall differences between the 2 paths. For those with specific interests in investigative grant-funded research or experimental therapeutics, academia is likely to be the most impactful for your practice. However, for the vast majority of FITs, both the academic and nonacademic career paths can be equally rewarding. As for me, when I deliberate on the choice between academic versus private practice cardiology, I believe that I am most likely to thrive as a clinician-educator because of my passion for teaching and love for patient care. Such an opportunity may come by way of an academic job or in a large private practice that offers exposure to senior mentors invested in my success and the chance to teach residents and fellows. We have all spent several years in training, and so it is paramount that we each find opportunities that foster our growth and keep us engaged. In the final analysis, we should strive to be well trained, enabled to use our skills, care optimally for our patients, and most of all: be inspired.